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Yoneda H, Takeda S, Saeki M, Iwatsuki K, Yamamoto M, Tatebe M, Hirata H. Utility of severity scoring systems for mangled upper limb salvage: A systematic review and meta-analysis. Injury 2024; 55:111447. [PMID: 38417237 DOI: 10.1016/j.injury.2024.111447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Revised: 02/18/2024] [Accepted: 02/20/2024] [Indexed: 03/01/2024]
Abstract
BACKGROUND The purpose of scoring systems is to aid in the decision-making process of whether to salvage or amputate mangled extremities, but their efficacy for upper limbs is uncertain. In this study, we examined the predictive potential of scoring systems for upper limb salvage. METHODS Two investigators undertook a systematic search of 3 leading databases for English or Japanese literature from 1985, when the first scoring system to evaluate mangled extremities was proposed, until January 2022. To be eligible, studies must have had upper extremity limb salvage or amputation as an outcome, and identified the scoring system used and treatment outcome in individual cases. RESULTS Ten studies (N = 338) of the Mangled Extremity Scoring System (MESS) were ultimately included in the meta-analysis. The pooled sensitivity and specificity were 0.95 (95 % CI = 0.69-0.99) and 0.81 (0.65-0.91), respectively. The area under the hierarchical summary receiver operating characteristic curve was 0.95 (0.93-0.97). A subgroup analysis showed lower specificity in isolated vascular injuries. Scoring systems other than MESS were ineligible for the quantitative synthesis because none were examined in an adequate number of publications. CONCLUSION The pooled sensitivity and specificity for MESS were comparable to those reported for the lower extremities. The specificity suggests that limb salvage was achieved in at least 20 % of the patients whose MESS was above the threshold beyond which amputation is indicated. Given the likelihood of upper extremity functional limitations following amputation and the drawbacks of prostheses, we conclude that current scoring systems poorly predict salvageability of a mangled upper extremity and should not be used to justify amputation.
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Affiliation(s)
- Hidemasa Yoneda
- Department of Human Enhancement and Hand surgery, Nagoya University, Nagoya, Aichi, Japan.
| | - Shinsuke Takeda
- Orthopedic surgery of Toyohashi Municipal Hospital, Toyohashi, Aichi, Japan
| | - Masaomi Saeki
- Department of Human Enhancement and Hand surgery, Nagoya University, Nagoya, Aichi, Japan
| | - Katsuyuki Iwatsuki
- Department of Human Enhancement and Hand surgery, Nagoya University, Nagoya, Aichi, Japan
| | - Michiro Yamamoto
- Department of Human Enhancement and Hand surgery, Nagoya University, Nagoya, Aichi, Japan
| | - Masahiro Tatebe
- Othopedic surgery of Anjo Kosei Hospital, Anjo, Aichi, Japan
| | - Hitoshi Hirata
- Department of Human Enhancement and Hand surgery, Nagoya University, Nagoya, Aichi, Japan
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Kee HT, Jaapar MS, Arumugam M, Mohamed Saaid F, Looi C, Che-Hamzah F. Reviving the Grasp: A Case Report on a Pioneering Approach to Managing Crush Syndrome and Unveiling the Occult Compartment Syndrome. Cureus 2024; 16:e55370. [PMID: 38562343 PMCID: PMC10982835 DOI: 10.7759/cureus.55370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/01/2024] [Indexed: 04/04/2024] Open
Abstract
A crush injury results directly from a crushing force, while crush syndrome, or traumatic rhabdomyolysis, manifests as systemic consequences stemming from the breakdown of muscle cells. Hand crush injuries present intricate challenges involving damage to multiple structures, tissue loss, and potential digit amputation, often caused by high-energy trauma. Each case demands a unique management plan, with the critical decision between limb salvage and amputation. Early intervention to restore vascularity is pivotal for preserving hand function. The complexity is heightened by the occult compartment syndrome, characterized by increased pressure causing neurovascular compromise without external signs. A patient with an insensate limb due to ipsilateral pan brachial plexus injury (BPI) adds an additional layer of complexity to the management journey, emphasizing the need for a multidisciplinary approach. This case is unique and underscores the importance of prioritizing reconstruction, identifying crush syndrome and the occult compartment syndrome, and employing a strategic, decisive approach that includes various surgical techniques for optimal outcomes in complex hand injuries.
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Affiliation(s)
- Hoe Teong Kee
- Orthopaedics and Traumatology, Hospital Sultan Abdul Aziz Shah, Serdang, MYS
| | - Mohd Shahril Jaapar
- Orthopaedics and Traumatology, Hospital Sultan Abdul Aziz Shah, Serdang, MYS
| | - Manohar Arumugam
- Hand and Microsurgery Unit, Hospital Sultan Abdul Aziz Shah, Serdang, MYS
| | | | - Collin Looi
- Hand and Microsurgery Unit, Hospital Sultan Abdul Aziz Shah, Serdang, MYS
| | - Fahrudin Che-Hamzah
- Orthopaedics and Traumatology, Hospital Sultan Abdul Aziz Shah, Serdang, MYS
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Yao PF, Diao YD, McMullen EP, Manka M, Murphy J, Lin C. Predicting amputation using machine learning: A systematic review. PLoS One 2023; 18:e0293684. [PMID: 37934767 PMCID: PMC10629636 DOI: 10.1371/journal.pone.0293684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Accepted: 10/17/2023] [Indexed: 11/09/2023] Open
Abstract
Amputation is an irreversible, last-line treatment indicated for a multitude of medical problems. Delaying amputation in favor of limb-sparing treatment may lead to increased risk of morbidity and mortality. This systematic review aims to synthesize the literature on how ML is being applied to predict amputation as an outcome. OVID Embase, OVID Medline, ACM Digital Library, Scopus, Web of Science, and IEEE Xplore were searched from inception to March 5, 2023. 1376 studies were screened; 15 articles were included. In the diabetic population, models ranged from sub-optimal to excellent performance (AUC: 0.6-0.94). In trauma patients, models had strong to excellent performance (AUC: 0.88-0.95). In patients who received amputation secondary to other etiologies (e.g.: burns and peripheral vascular disease), models had similar performance (AUC: 0.81-1.0). Many studies were found to have a high PROBAST risk of bias, most often due to small sample sizes. In conclusion, multiple machine learning models have been successfully developed that have the potential to be superior to traditional modeling techniques and prospective clinical judgment in predicting amputation. Further research is needed to overcome the limitations of current studies and to bring applicability to a clinical setting.
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Affiliation(s)
- Patrick Fangping Yao
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Yi David Diao
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Eric P. McMullen
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Marlin Manka
- Department of Computer Science, University of Western Ontario, London, ON, Canada
| | - Jessica Murphy
- Division of Physical Medicine and Rehabilitation, McMaster University, Hamilton, ON, Canada
| | - Celina Lin
- Division of Physical Medicine and Rehabilitation, McMaster University, Hamilton, ON, Canada
- Division of Physical Medicine and Rehabilitation, Hamilton Health Sciences, Hamilton, ON, Canada
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Badalamenti G, Ferrer C, Calvagna C, Franchin M, Piffaretti G, Taglialavoro J, Bassini S, Griselli F, Grando B, Lepidi S, D'Oria M. Major vascular traumas to the neck, upper limbs, and chest: Clinical presentation, diagnostic approach, and management strategies. Semin Vasc Surg 2023; 36:258-267. [PMID: 37330239 DOI: 10.1053/j.semvascsurg.2023.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 04/14/2023] [Accepted: 04/17/2023] [Indexed: 06/19/2023]
Abstract
Major vascular traumas to the neck, upper limbs, and chest may arise from penetrating and/or blunt mechanisms, resulting in a range of clinical scenarios. Lesions to the carotid arteries may also lead to neurologic complications, such as stroke. The increasing use of invasive arterial access for diagnostic and/or interventional purposes has increased the rate of iatrogenic injuries, which usually occur in older and hospitalized patients. Bleeding control and restoration of perfusion represent the two main goals of treatment for vascular traumatic lesions. Open surgery still represents the gold standard for most lesions, although endovascular approaches have increasingly emerged as feasible and effective options, particularly for management of subclavian and aortic injuries. In addition to advanced imaging (including ultrasound, contrast-enhanced cross-sectional imaging, and arteriography) and life support measures, multidisciplinary care is required, particularly in the setting of concomitant injuries to the bones, soft tissues, or other vital organs. Modern vascular surgeons should be familiar with the whole armamentarium of open and endovascular techniques needed to manage major vascular traumas safely and promptly.
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Affiliation(s)
- Giovanni Badalamenti
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste ASUGI, Strada di Fiume 447, Trieste, Italy
| | - Ciro Ferrer
- Vascular and Endovascular Surgery Unit, 90352 San Giovanni - Addolorata Hospital, Roma, Italy
| | - Cristiano Calvagna
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste ASUGI, Strada di Fiume 447, Trieste, Italy
| | - Marco Franchin
- Vascular Surgery Unit, Circolo University Teaching Hospital, University of Insubria - ASST Settelaghi, Varese, Italy
| | - Gabriele Piffaretti
- Vascular Surgery Unit, Circolo University Teaching Hospital, University of Insubria - ASST Settelaghi, Varese, Italy
| | - Jacopo Taglialavoro
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste ASUGI, Strada di Fiume 447, Trieste, Italy
| | - Silvia Bassini
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste ASUGI, Strada di Fiume 447, Trieste, Italy
| | - Filippo Griselli
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste ASUGI, Strada di Fiume 447, Trieste, Italy
| | - Beatrice Grando
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste ASUGI, Strada di Fiume 447, Trieste, Italy
| | - Sandro Lepidi
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste ASUGI, Strada di Fiume 447, Trieste, Italy
| | - Mario D'Oria
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste ASUGI, Strada di Fiume 447, Trieste, Italy.
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Long B, Liang SY, Gottlieb M. Crush injury and syndrome: A review for emergency clinicians. Am J Emerg Med 2023; 69:180-187. [PMID: 37163784 DOI: 10.1016/j.ajem.2023.04.029] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 04/17/2023] [Indexed: 05/12/2023] Open
Abstract
INTRODUCTION Primary disasters may result in mass casualty events with serious injuries, including crush injury and crush syndrome. OBJECTIVE This narrative review provides a focused overview of crush injury and crush syndrome for emergency clinicians. DISCUSSION Millions of people worldwide annually face natural or human-made disasters, which may lead to mass casualty events and severe medical issues including crush injury and syndrome. Crush injury is due to direct physical trauma and compression of the human body, most commonly involving the lower extremities. It may result in asphyxia, severe orthopedic injury, compartment syndrome, hypotension, and organ injury (including acute kidney injury). Crush syndrome is the systemic manifestation of severe, traumatic muscle injury. Emergency clinicians are at the forefront of the evaluation and treatment of these patients. Care at the incident scene is essential and focuses on treating life-threatening injuries, extrication, triage, fluid resuscitation, and transport. Care at the healthcare facility includes initial stabilization and trauma evaluation as well as treatment of any complication (e.g., compartment syndrome, hyperkalemia, rhabdomyolysis, acute kidney injury). CONCLUSIONS Crush injury and crush syndrome are common in natural and human-made disasters. Emergency clinicians must understand the pathophysiology, evaluation, and management of these conditions to optimize patient care.
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Affiliation(s)
- Brit Long
- SAUSHEC, Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX 78234, USA.
| | - Stephen Y Liang
- Divisions of Emergency Medicine and Infectious Diseases, Washington University School of Medicine, 660 S. Euclid Ave, St. Louis, MO 63110, USA.
| | - Michael Gottlieb
- Ultrasound Director, Assistant Professor, Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, USA
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Mabarak D, Behzadi F, Yang M, Wozniak A, Patel P, Aulivola B. Concomitant Orthopedic Injury is the Strongest Predictor of Amputation in Extremity Vascular Trauma. Ann Vasc Surg 2023; 91:161-167. [PMID: 36563845 PMCID: PMC10068617 DOI: 10.1016/j.avsg.2022.12.065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 11/30/2022] [Accepted: 12/02/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Although the risk of extremity amputation related to an isolated vascular injury is low, it increases significantly with concomitant orthopedic injury. Our study aims to evaluate and quantify the impact of risk factors associated with trauma-related extremity amputation in patients with vascular injury. We sought to determine whether there are other potential predictors of amputation. METHODS A retrospective review of patients with extremity vascular injury presenting to a single level 1 academic trauma center between January 1, 2007, and December 31, 2018, was performed. All patients diagnosed with major vascular injury to the upper or lower extremity were included. Data on patient demographics, medical comorbidities, anatomic location of vascular injury, and the presence of soft tissue or orthopedic injury were collected. The main outcome measure was major amputation of the affected extremity. Major amputation included below-the-knee amputation, above-the-knee amputation, as well as any amputation of the upper extremity at or proximal to the wrist. RESULTS We identified 250 extremities with major vascular injury in 234 patients. Of these, 216 (86.4%) were male and 34 (13.6%) female. The mean age was 32.2 years (range 18-79 years) and mean follow-up was 6.9 (standard deviation: 3.3) years. Just over half of injuries, 130 (52.0%) involved the lower extremity. Forty extremities (29 lower and 11 upper), or 16.0%, of total injured extremities, required major amputation during the follow-up period. Concomitant orthopedic injury was present in 106 of 250 (42%) injured extremities. Using univariable logistic regression models, variables with a significant association with major amputation included older age, higher body mass index, blunt mechanism of injury, concomitant orthopedic injury, soft tissue injury, and nerve injury, and the need for fasciotomy (P < 0.05). In multivariable analyses, blunt mechanism of injury (odds ratio [OR] (confidence ratio {CI}): 6.51 (2.29, 18.46), P < 0.001) and concomitant orthopedic injury (OR [CI]: 7.23 [2.22, 23.55], P = 0.001) remained significant predictors of amputation. CONCLUSIONS Concomitant orthopedic injury and blunt mechanism in the setting of vascular injury are associated with a higher likelihood of amputation in patients with extremity vascular injury. Further development of a vascular extremity injury protocol may be needed to enhance limb salvage. Findings may guide patient discussion regarding limb-salvage decision-making.
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Affiliation(s)
| | | | - Maelee Yang
- Department of Plastic and Reconstructive Surgery, Loyola University Medical Center, Maywood, IL
| | | | - Purvi Patel
- Department of Trauma, Surgical Critical Care, and Burns, Loyola University Medical Center, Maywood, IL
| | - Bernadette Aulivola
- Department of Vascular Surgery and Endovascular Therapy, Loyola University Medical Center, Maywood, IL.
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Gautam P, Gyawali S, Mainali P, Niraula H, Shrestha J, Lohani I. Mangled right hand: A case report. Int J Surg Case Rep 2022; 102:107846. [PMID: 36577263 PMCID: PMC9803771 DOI: 10.1016/j.ijscr.2022.107846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 12/20/2022] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION The mangled hand is a complex and uncommon injury of the upper extremity. It involves injury to multiple structures i.e., bone, soft tissue, and neurovascular bundles of the hand leading to loss of function and viability. These injuries are usually caused due to trauma from high-energy equipment. PRESENTATION OF CASE A 32-year female presented with a crush injury to her right hand by a grass-cutting machine. The right hand was de-vascularised with injury to both radial and ulnar arteries. She had multiple lacerations, fractures of the distal radius and ulna, and multiple fractures of the metacarpals and phalanges. An initial revascularization procedure with a vein graft was done in the ulnar artery, joints were stabilized, and planned for reconstructive surgery at a later date. DISCUSSION Initial evaluation includes a decision to salvage or amputate the limb. Early intervention to restore vascularity is key to salvaging a mangled hand. This should be followed by a multidisciplinary team approach. Preference is given to reconstruction procedures rather than amputation and prosthesis procedures. CONCLUSION Early intervention, a multispecialty approach, and staged procedures are required for the successful management of a mangled hand. Eventually, physiotherapy has a key role in the restoration of function.
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Affiliation(s)
- P. Gautam
- Department of General Surgery, Patan Academy of Health Sciences, Lagankhel, Lalitpur, Nepal
| | - S. Gyawali
- Department of General Surgery, Patan Academy of Health Sciences, Lagankhel, Lalitpur, Nepal,Corresponding author at: Manbhawan, Lalitpur, Nepal.
| | - P. Mainali
- Department of Plastic Surgery and Burns, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
| | - H. Niraula
- Department of Plastic Surgery and Burns, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
| | - J.M. Shrestha
- Department of Plastic Surgery and Burns, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
| | - I. Lohani
- Department of Plastic Surgery and Burns, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
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K A, Ayyan SM, Ezhilkugan G, Kumar P, Rajendran G. A Rare Case of Limb-Threatening Injury Secondary to Extrinsic Vascular Compression Following Crocodile Bite. Wilderness Environ Med 2022; 33:355-360. [PMID: 35863955 DOI: 10.1016/j.wem.2022.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Revised: 05/10/2022] [Accepted: 05/11/2022] [Indexed: 11/17/2022]
Abstract
Crocodile bites lead to fatal and nonfatal outcomes in humans. Mugger crocodiles (Crocodylus palustris) and saltwater crocodiles (Crocodylus porosus) are common in India. Most crocodile bites can cause severe injuries, especially to the extremities, due to the substantial bite force of the crocodile, which typically leads to extensive tissue damage, fractures, amputations, and vascular injuries. We report the case of a crocodile bite victim who presented with features of acute limb ischemia, was found to have vascular thrombosis of the common femoral artery, and was experiencing complete compression of the femoral vein due to external vascular compression by a hematoma. We discuss various injury mechanisms sustained in crocodile bites and the roles of point-of-care ultrasound and continuous tomography angiography, which could help identify these injuries. After thrombectomy and hematoma evacuation the patient recovered and was discharged without any physical dysfunction.
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Affiliation(s)
- Aswin K
- Department of Emergency Medicine & Trauma, Jawaharlal Institute of Postgraduate Medical Education & Research, Puducherry, India
| | - S Manu Ayyan
- Department of Emergency Medicine & Trauma, Jawaharlal Institute of Postgraduate Medical Education & Research, Puducherry, India.
| | - Ganessane Ezhilkugan
- Department of Emergency Medicine & Trauma, Jawaharlal Institute of Postgraduate Medical Education & Research, Puducherry, India
| | - Praveen Kumar
- Department of Emergency Medicine & Trauma, Jawaharlal Institute of Postgraduate Medical Education & Research, Puducherry, India
| | - Gunaseelan Rajendran
- Department of Emergency Medicine & Trauma, Jawaharlal Institute of Postgraduate Medical Education & Research, Puducherry, India
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Gao C, Yang L, Ju J, Gao Y, Zhang K, Wu M, Yang L, Lu X, Hou R, Guo Q. Risk and prognostic factors of replantation failure in patients with severe traumatic major limb mutilation. Eur J Trauma Emerg Surg 2022; 48:3203-3210. [PMID: 35050386 PMCID: PMC9360147 DOI: 10.1007/s00068-021-01876-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 12/04/2021] [Indexed: 11/06/2022]
Abstract
Purpose Traumatic mutilation of major limbs can result in limb loss, motor disability, or death. Patients who had replantation failure needed to undergo additional surgeries (even amputation) and had a longer length of hospital stay. Here, we determined the risk and prognostic factors of replantation failure in patients with traumatic major limb mutilation. Methods This retrospective study included adult inpatients with severed traumatic major limb mutilation who underwent replantation from Suzhou Ruixing Medical Group from October 18, 2016 to July 31, 2020. Demographic, and clinical characteristics including traumatic conditions, laboratory findings, mangled extremity severity scores (MESS), treatments, and outcomes of the patients were collected. Data were used to analyze predictors and risk factors for replantation failure. Results Among the 66 patients, 48 (72.7%) were males, the median age was 47.0 years old. Replantation failure occurred in 48 patients (72.7%). The area under the curve of the joint prediction of lactic acid on admission, 72-h cumulative fluid balance, and albumin level immediately postoperatively was 0.838 (95% confidence interval [CI], 0.722–0.954; P < 0.001) with a sensitivity of 89.7% and a specificity of 69.2%. Lower limb trauma (odds ratio [OR] 8.65, 95% CI 1.64–45.56, P = 0.011), mangled extremity severity scores (OR 2.24, 95% CI 1.25–4.01, P = 0.007), and first 72-h cumulative fluid balance > 4885.6 mL (OR 10.25, 95% CI 1.37–76.93, P = 0.024) were independent risk factors for replantation failure. Conclusions Lower limb trauma, mangled extremity severity scores, and cumulative water balance were associated with replantation failure, implying that fluid management is necessary for major limb salvage. More studies are needed to explore the predictive power of indicators related to tissue oxygenation and wound healing for replantation failure. Supplementary Information The online version contains supplementary material available at 10.1007/s00068-021-01876-w.
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Affiliation(s)
- Chang Gao
- Department of Emergency and Critical Care Medicine, Dushu Lake Hospital Affiliated to Soochow University (Suzhou Dushu Lake Hospital), Suzhou, Jiangsu, China
- Medical Center of Soochow University, Suzhou, Jiangsu, China
| | - Ling Yang
- Medical College of Soochow University, Suzhou, Jiangsu, China
| | - Jihui Ju
- Department of Orthopaedic, Ruihua Affiliated Hospital of Soochow University (Suzhou Ruixing Medical Group), Suzhou, Jiangsu, China
| | - Ye Gao
- Department of Critical Care Medicine, Taicang Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Keran Zhang
- Department of Critical Care Medicine, Ruihua Affiliated Hospital of Soochow University (Suzhou Ruixing Medical Group), Suzhou, Jiangsu, China
| | - Mingming Wu
- Department of Critical Care Rehabilitation Medicine, Suzhou Ruisheng Rehabilitation Hospital (Suzhou Ruixing Medical Group), Suzhou, Jiangsu, China
| | - Lijuan Yang
- Medical College of Soochow University, Suzhou, Jiangsu, China
| | - Xiaoting Lu
- Department of Emergency and Critical Care Medicine, Dushu Lake Hospital Affiliated to Soochow University (Suzhou Dushu Lake Hospital), Suzhou, Jiangsu, China
- Medical Center of Soochow University, Suzhou, Jiangsu, China
| | - Ruixing Hou
- Department of Orthopaedic, Ruihua Affiliated Hospital of Soochow University (Suzhou Ruixing Medical Group), Suzhou, Jiangsu, China.
| | - Qiang Guo
- Department of Emergency and Critical Care Medicine, Dushu Lake Hospital Affiliated to Soochow University (Suzhou Dushu Lake Hospital), Suzhou, Jiangsu, China.
- Medical Center of Soochow University, Suzhou, Jiangsu, China.
- The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China.
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Stefano L, Giovanni R, Pietro DF, Matteo O, Lara L, Nicola F. Which is the best score and classification system for complex injuries of the limbs? Some recommendations based on a systematic literature review. Eur J Plast Surg 2022. [DOI: 10.1007/s00238-021-01901-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Georgescu AV, Battiston B. Mangled upper extremity: Our strategy of reconstruction and clinical results. Injury 2021; 52:3588-604. [PMID: 33867148 DOI: 10.1016/j.injury.2021.04.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 03/23/2021] [Accepted: 04/04/2021] [Indexed: 02/02/2023]
Abstract
The management of mangled upper extremity is very challenging because the anatomical complexity of the region, the large number of possible involved anatomical elements, and the necessity of obtaining a good functionality. The impressive development of microsurgical techniques in the last decades contributed a lot to the salvage of several extreme injuries with mangled extremities considered untreatable in the past. Such injuries can nowadays be successfully managed by means of replantation/revascularization or complex reconstruction by using simple or complex microsurgical flaps. The more important steps in managing a mangled upper extremity are the decision making, the moment of reconstruction, the debridement, and the reconstruction by using customized methods. The decision regarding extremity salvage or amputation has to be individualized taking into account general and local factors. These factors influence the absolute or relative indication, but the final decision is up to the experience of every single surgical team. The timing of reconstruction is still a large debated subject, but it seems that the reconstruction as soon as possible is in the advantage of obtaining a much better functional recovery. The debridement should be very carefully performed in the attempt to preserve all the essential anatomical elements able to allow the obtaining of enough functionality. Most of these lesions are accompanied by simple or complex tissue defects. The coverage of these defects needs customized simple or composite flaps used both as free and local/regional microsurgical flaps. Based on the experience regarding the strategy and management of the mangled upper extremity in two European hand trauma centers, we conclude that the keystone in savaging this kind of lesions is represented by a very carefully assessment of the patient and lesion, an enough aggressive debridement, and an as soon as possible reconstruction.
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12
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Nayar SK, Alcock HMF, Edwards DS. Primary amputation versus limb salvage in upper limb major trauma: a systematic review. Eur J Orthop Surg Traumatol 2021; 32:395-403. [PMID: 34050819 PMCID: PMC8924095 DOI: 10.1007/s00590-021-03008-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 05/11/2021] [Indexed: 11/03/2022]
Abstract
PURPOSE Severe upper limb injuries can result in devastating consequences to functional and psychological well-being. Primary objectives of this review were to evaluate indications for amputation versus limb salvage in upper limb major trauma and whether any existing scoring systems can aid in decision-making. Secondary objectives were to assess the functional and psychological outcomes from amputation versus limb salvage. METHODS A systematic review was carried out in accordance with PRISMA guidelines. A search strategy was conducted on the MEDLINE, EMBASE, and Cochrane databases. Quality was assessed using the ROBINS-I tool. The review protocol was registered in PROSPERO. RESULTS A total of 15 studies met inclusion criteria, encompassing 6113 patients. 141 underwent primary amputation and 5972 limb salvage. General indications for amputation included at least two of the following: uncontrollable haemodynamic instability; extensive and concurrent soft tissue, bone, vascular and/or nerve injuries; prolonged limb ischaemia; and blunt arterial trauma or crush injury. The Mangled Extremity Severity Score alone does not accurately predict need for amputation, however, the Mangled Extremity Syndrome Index may be a more precise tool. Comparable patient-reported functional and psychological outcomes are seen between the two treatment modalities. CONCLUSIONS Decision regarding amputation versus limb salvage of the upper limb is multifactorial. Current scoring systems are predominantly based on lower limb trauma, with lack of robust evidence to guide management of the upper extremity. Further high-quality studies are required to validate scoring systems which may aid in decision-making and provide further information on the outcomes from the two treatment options.
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Affiliation(s)
- Sandeep Krishan Nayar
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, 4 Newark Street, London, E1 2AT, UK.
| | - Harry M F Alcock
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, 4 Newark Street, London, E1 2AT, UK
| | - Dafydd S Edwards
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, 4 Newark Street, London, E1 2AT, UK
- Department of Trauma and Orthopaedics, Barts Health NHS Trust, London, UK
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13
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Benanti E, De Santis G, Leti Acciaro A, Colzani G, Baccarani A, Starnoni M. Soft tissue coverage of the upper limb: A flap reconstruction overview. Ann Med Surg (Lond) 2020; 60:338-343. [PMID: 33224487 PMCID: PMC7666305 DOI: 10.1016/j.amsu.2020.10.069] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 10/29/2020] [Accepted: 10/31/2020] [Indexed: 12/16/2022] Open
Abstract
Different opinions about the reconstructive choice for upper limb are described in literature: advancement or rotation flaps, regional flaps and free flaps are the most common reconstructive options. Local and regional flaps can be used to cover small defects while large wounds require the use of free flaps or distant pedicled flaps. The coverage of large wounds opens a discussion about when to use free flaps and when distant pedicled flaps. This review will describe the different methods used for the coverage of soft tissues injuries affecting hand and/or forearm (excluding fingers). The aim is to show all flap reconstructive options in order to support the inexperienced surgeon during the management of traumatic injuries of the upper limb.
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Affiliation(s)
- Elisa Benanti
- Department of Medical and Surgical Sciences, Division of Plastic Surgery, University of Modena and Reggio Emilia, Policlinico of Modena, Largo Pozzo 71, 41124, Modena, Italy
| | - Giorgio De Santis
- Department of Medical and Surgical Sciences, Division of Plastic Surgery, University of Modena and Reggio Emilia, Policlinico of Modena, Largo Pozzo 71, 41124, Modena, Italy
| | - Andrea Leti Acciaro
- Department of Orthopaedics and Traumatology, Division of Hand Surgery and Microsurgery, University of Modena and Reggio Emilia, Policlinico of Modena, Largo Pozzo 71, 41124, Modena, Italy
| | - Giulia Colzani
- Department of Orthopaedics and Traumatology, Division of Hand Surgery and Microsurgery, University of Torino, CTO Hospital, Via Zuretti 29, 10126, Torino, Italy
| | - Alessio Baccarani
- Department of Medical and Surgical Sciences, Division of Plastic Surgery, University of Modena and Reggio Emilia, Policlinico of Modena, Largo Pozzo 71, 41124, Modena, Italy
| | - Marta Starnoni
- Department of Medical and Surgical Sciences, Division of Plastic Surgery, University of Modena and Reggio Emilia, Policlinico of Modena, Largo Pozzo 71, 41124, Modena, Italy
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14
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Savetsky IL, Aschen SZ, Salibian AA, Howard K, Lee ZH, Frangos SG, Thanik VD. A Novel Mangled Upper Extremity Injury Assessment Score. Plast Reconstr Surg Glob Open 2019; 7:e2449. [PMID: 31942406 DOI: 10.1097/GOX.0000000000002449] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 07/22/2019] [Indexed: 11/26/2022]
Abstract
Managing mangled upper extremity injuries is a challenging problem because multiple tissue components including soft tissue, muscle, tendon, bone, nerves, and vessels are involved. The complexity of these injuries has hindered the development of accurate scoring systems and treatment algorithms. Methods Patients with mangled upper extremities presenting to a metropolitan level 1 trauma center in New York City over a 10-year period were identified. A mangled upper extremity was defined as any injury to ≥3 tissue components involving the extremity proximal to the digit. Results The injuries and outcomes of 76 patients were evaluated and used to create a Mangled Upper Extremity Score (MUES). One point was assigned for each of the following injury characteristics: patient age >40, fasciotomy needed, bony fixation required, bony defect present, revascularization required, crush injury mechanism, degloving or avulsion injury present, and a soft tissue defect >50 cm2. The MUES correlated with the number of complications (P value = 1.96 × 10-7) and length of hospital stay (P value = 3.95 × 10-7). Next, a Mangled Extremity Severity Score (MESS) equivalent was calculated for each patient. There was no correlation between the MESS and the number of complications (P value = 0.92) or length of hospital stay (P value = 0.35). Conclusions Existing extremity scoring systems, including the MESS, are not reliable in predicting the success of limb salvage attempts or outcomes of mangled upper extremity injuries. The MUES developed in this study correlates significantly with important outcome measures including the number of hospital complications and length of hospital stay.
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15
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Sabapathy SR, Venkatramani H, Mohan M. Initial Assessment, Debridement, and Decision Making in the Salvage of Severely Injured Lower Extremity. Indian J Plast Surg 2019; 52:10-16. [PMID: 31456608 PMCID: PMC6664836 DOI: 10.1055/s-0039-1689741] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
An open fracture with extensive skin and soft tissue loss is considered as a severely injured lower extremity. Advances in rapid transport, resuscitation, skeletal fixation, and microsurgical techniques to cover large soft tissue and bone defects have made possible the salvage of these severely injured limbs. Salvage exercise is skill and resource intensive and could take a long time frame. The goal of management is to obtain painless independent weight bearing walking in a time frame and cost that the patient can afford. Decisions taken and the quality of care provided on day 1 determine the ultimate success. Inappropriate decisions and treatment lead to increased morbidity and secondary amputation. Infection is the commonest complication. Limb salvage scores are helpful to predict salvage and guide the sequence of treatment. Once the decision is taken for salvage, debridement, early skeletal fixation, and soft tissue cover are the key to success.
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Affiliation(s)
- S Raja Sabapathy
- Department of Plastic Surgery, Ganga Medical Centre and Hospitals, Coimbatore, Tamil Nadu, India
| | - Hari Venkatramani
- Department of Plastic Surgery, Ganga Medical Centre and Hospitals, Coimbatore, Tamil Nadu, India
| | - Monusha Mohan
- Department of Plastic Surgery, Ganga Medical Centre and Hospitals, Coimbatore, Tamil Nadu, India
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16
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Grigorian A, Wilson SE, de Virgilio C, Kabutey NK, Fujitani RM, Gabriel V, Schubl SD, Joe V, Nahmias J. Humerus fracture and combined venous injury increases limb loss in axillary or subclavian artery injury. Vascular 2018; 27:252-259. [PMID: 30426848 DOI: 10.1177/1708538118811231] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Axillosubclavian vessel injury is rare, with most cases occurring after penetrating trauma. A prior database (2002-2006) analysis demonstrated an overall limb loss rate of 2.9%, with no difference between isolated arterial axillosubclavian vessel injury and combined artery/vein axillosubclavian vessel injury. Given increases in advanced vascular surgical techniques, as well as improved multidisciplinary care and expeditious diagnosis with computed tomography angiography, we hypothesized the national rate of limb loss in patients with arterial axillosubclavian vessel injury has decreased. In addition, we attempted to identify current predictors for limb loss in arterial axillosubclavian vessel injury. Finally, we hypothesized that combined artery/vein axillosubclavian vessel injury, as well as associated brachial plexus injury will have a higher risk for limb-loss and mortality compared to isolated arterial axillosubclavian vessel injury. METHODS A retrospective analysis of the National Trauma Data Bank was performed between 2007 and 2015. All patients ≥ 18 years of age with arterial axillosubclavian vessel injury were included. The primary outcome was limb loss. After a univariable logistic regression model identified significant covariates, we performed a multivariable logistic regression for analysis. RESULTS Of the total 5,494,609 trauma admissions, 3807 patients had arterial axillosubclavian vessel injury (<0.1%). Of these, 3137 (82.4%) had isolated arterial axillosubclavian vessel injury and 670 (17.6%) had combined artery/vein axillosubclavian vessel injury. The overall limb loss rate was 2.4% (from 2.9% in 2006, p = 0.47). After adjusting for covariates, independent risk factors for limb loss included a combined artery/vein axillosubclavian vessel injury (odds ratio = 3.54, confidence interval = 2.06-6.11, p < 0.001), blunt mechanism (odds ratio = 7.81, confidence interval = 4.21-14.48, p < 0.001), open repair (odds ratio = 2.37, confidence interval = 1.47-3.82, p < 0.001), and open proximal humerus fracture (odds ratio = 8.50, confidence interval = 4.97-14.54, p < 0.001). An associated brachial plexus injury was not associated with limb loss ( p = 0.37). Combined artery/vein axillosubclavian vessel injury was associated with higher risk for mortality compared to isolated arterial axillosubclavian vessel injury (odds ratio = 2.17, confidence interval = 1.73-2.71, p < 0.001). CONCLUSIONS The national rate of limb loss in trauma patients with arterial axillosubclavian vessel injury has not changed in the past decade. A combined artery/vein axillosubclavian vessel injury is an independent risk factor for limb loss, as well as open repair. However, the strongest risk factor is an open proximal humerus fracture. An associated brachial plexus injury is not associated with increased risk of limb loss. Patients with combined artery/vein axillosubclavian vessel injury have a twofold increased risk of death compared to patients with isolated arterial axillosubclavian vessel injury.
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Affiliation(s)
- Areg Grigorian
- 1 Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, University of California, Irvine, Orange, CA, USA
| | - Samuel E Wilson
- 1 Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, University of California, Irvine, Orange, CA, USA
| | - Christian de Virgilio
- 2 Department of Surgery, University of California, Harbor-Los Angeles, Los Angeles, CA, USA
| | - Nii-Kabu Kabutey
- 1 Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, University of California, Irvine, Orange, CA, USA
| | - Roy M Fujitani
- 1 Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, University of California, Irvine, Orange, CA, USA
| | - Viktor Gabriel
- 1 Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, University of California, Irvine, Orange, CA, USA
| | - Sebastian D Schubl
- 1 Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, University of California, Irvine, Orange, CA, USA
| | - Victor Joe
- 1 Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, University of California, Irvine, Orange, CA, USA
| | - Jeffry Nahmias
- 1 Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, University of California, Irvine, Orange, CA, USA
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17
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Abstract
Background There are few recent data examining the epidemiology of severe upper-extremity trauma in non-military patients. We used the National Trauma Data Bank (NTDB) to investigate the epidemiology and descriptive characteristics of upper-extremity amputations in U.S. trauma centers. Methods We queried the 2009 to 2012 NTDB research datasets for patients undergoing major upper-extremity amputation and extracted characteristics of the patient population, injury distribution, and treating facilities. In addition, multivariable regression models were fit to identify correlates of reoperation, major in-hospital complications, duration of hospitalization, and in-hospital mortality. Results A total of 1,386 patients underwent a major upper-extremity amputation secondary to a trauma-related upper-extremity injury, representing 46 per 100,000 NTDB trauma admissions from 2009 to 2012. The most frequent definitive procedures performed were amputations through the humerus (35%), forearm (30%), and hand (14%). The average duration of hospitalization for all amputees was 17 days. Thirty-one percent of patients underwent at least 1 reoperation. The rate of reoperation was significantly higher at university-associated hospitals compared with nonteaching or community hospitals (p < 0.0001). Patients who had at least 1 reoperation stayed in the hospital approximately 7 days longer than patients who did not undergo reoperation. The Injury Severity Score, hospital teaching status, concomitant neurovascular injury, and occurrence of a complication were significantly associated with reoperation. Conclusions The present study provides an updated report on the epidemiology and characteristics of trauma-related major upper-extremity amputation in the U.S. civilian population. Additional work is necessary to assess the long-term outcomes following attempted upper-extremity salvage. The population-level data provided by the present study may help to inform the design and implementation of future studies on the optimum treatment for this survivable but life-altering injury.
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Affiliation(s)
- Elizabeth Inkellis
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California
| | - Eric Edison Low
- University of California, San Francisco School of Medicine, San Francisco, California
| | - Christopher Langhammer
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California
| | - Saam Morshed
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California.,Orthopaedic Trauma Institute, San Francisco, California
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18
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Panattoni JB, Ahmed MM, Busel GA. An ABC Technical Algorithm to Treat the Mangled Upper Extremity: Systematic Surgical Approach. J Hand Surg Am 2017; 42:934.e1-934.e10. [PMID: 28951098 DOI: 10.1016/j.jhsa.2017.08.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2017] [Accepted: 08/20/2017] [Indexed: 02/02/2023]
Abstract
Mangled upper extremity, as a result of trauma, is a life-altering event requiring a multidisciplinary approach for a successful outcome. All attempts are made to salvage the extremity and preserve function, which may require multiple complex procedures. This paper discusses the importance of a systematic reconstructive sequence and provides a review of commonly utilized techniques, supported with illustrative cases.
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19
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Abstract
Crush injuries of the hand are a rare but devastating phenomenon, with historically poor outcomes. A compressive force, usually caused by a high-energy mechanism such as a motor vehicle or industrial accident, crushes and transiently increases the pressures within the hand. This force acts on the incompressible blood in the vasculature and leads to a dramatic rise in tissue pressures and damage to multiple tissue types, including bones, blood vessels, nerves, and soft tissues. A wide zone of injury results from a delayed inflammatory reaction involving the zone bordering the crushed cells, which may initially belie the severity of the injury. As such, these injuries go on to produce tremendous inflammation and swelling, potentially followed by compartment syndrome or other vascular damage, infection, neurological injury, and tissue necrosis. Crush injuries with minimal skin disruptions can be particularly challenging to accurately diagnose and manage. This paper provides a review of the initial evaluation of hand crush injuries as well as short- and long-term management strategies.
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Affiliation(s)
- Avi D Goodman
- Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, Providence, Rhode Island.
| | - Christopher J Got
- Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Arnold-Peter C Weiss
- Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, Providence, Rhode Island
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20
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Abstract
Mutilated injuries need to be treated aggressively and appropriately to avoid amputation or severe disability in the individual. Assessment of the management of these injuries on a global level reveals that there is a gap between the need and availability of the skilled manpower to manage these injuries. There is also a gap in the utilization of the available services. These gaps need to be covered or narrowed as far as possible. Although some measures need policy changes and improvement of health care delivery infrastructure, simpler measures taken at the final health care delivery level can significantly improve the final outcome.
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Affiliation(s)
- S Raja Sabapathy
- Division of Plastic Surgery, Hand Surgery, Reconstructive Microsurgery and Burns, Ganga Hospital, 313, Mettupalayam Road, Coimbatore, Tamil Nadu 641 043, India.
| | - Praveen Bhardwaj
- Hand & Wrist Surgery and Reconstructive Microsurgery, Ganga Hospital, 313, Mettupalayam Road, Coimbatore, Tamil Nadu 641 043, India
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21
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Abstract
With the available microsurgical techniques, salvage of the limb can almost always provide a useful upper limb, even in the most complex combined injuries. Having a low threshold for revascularization of doubtfully viable extremities and making full use of the current armamentarium of soft tissue cover techniques, including flow through free flaps, will salvage many limbs. Secondary procedures, including free functioning muscle transfers and toe transfers, further increase the possible functional outcome. Even in the most complex combined injuries, intelligent reconstruction will obtain better outcomes than the best available prosthesis, making the efforts of salvage worthwhile.
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22
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Kamal A, Kanakeshwar RB, Shyam A, Jayaramaraju D, Agraharam D, Perumal R, Rajasekaran S. Variation in practice preferences in management of open injuries of extremities-an international survey by SICOT research academy. Int Orthop 2016; 41:3-11. [PMID: 27778039 DOI: 10.1007/s00264-016-3311-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Accepted: 10/03/2016] [Indexed: 01/04/2023]
Abstract
PURPOSE Open fractures are challenging injuries and there is a lot of variation in practice preferences which may reflect the wide variations in outcome in different units across the world. A survey was done amongst the international community of SICOT membership to document the practice preferences and variations. METHODS An online questionnaire containing 23 questions which were sub-divided into three sections covering the various aspects of open injury management was sent by email to orthopaedic trauma surgeons across the world. A total of 358 responses were evaluated and presented in this manuscript. RESULTS The SICOT study confirmed wide variation in practice protocols. About 94.7 % of orthopaedic surgeons around the world use the Gustillo Anderson scoring system for assessment of open injury and 50.6 % of surgeons prefer lavage in operation theatre. For lavage, 84.6 % of surgeons preferred normal saline and for antibiotic prophylaxis, 48.3 % used a combination of second generation cephalosporin, metronidazole and an aminoglycoside for a minimum of three to five days. In 88 % of patients, orthopaedic surgeons performed the initial debridement and 69.2 % surgeons aimed for debridement within six hours. Regarding wound management, 43.9 % units preferred and were capable of soft tissue cover within 72 hours and about 26.3 % surgeons combined definitive fixation along with plastic procedure. CONCLUSION Our study documented wide variations in practice preferences across the world and showed that information and awareness about current guidelines and practices will help many to update themselves in terms of basic questions about open fracture care.
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Affiliation(s)
- Arun Kamal
- Department of spine surgery, Ganga Hospital, 313, Mettupalayam road, Coimbatore, India
| | | | - Ashok Shyam
- Department of spine surgery, Ganga Hospital, 313, Mettupalayam road, Coimbatore, India
| | | | - Devendra Agraharam
- Department of spine surgery, Ganga Hospital, 313, Mettupalayam road, Coimbatore, India
| | - Ramesh Perumal
- Department of spine surgery, Ganga Hospital, 313, Mettupalayam road, Coimbatore, India
| | - Shanmuganathan Rajasekaran
- Department of spine surgery, Ganga Hospital, 313, Mettupalayam road, Coimbatore, India.
- Department of Orthopaedics & Spine surgery, Ganga Hospital, Mettuplayam road, Coimbatore, India.
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23
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Aszmann OC, Vujaklija I, Roche AD, Salminger S, Herceg M, Sturma A, Hruby LA, Pittermann A, Hofer C, Amsuess S, Farina D. Elective amputation and bionic substitution restore functional hand use after critical soft tissue injuries. Sci Rep 2016; 6:34960. [PMID: 27721419 PMCID: PMC5056343 DOI: 10.1038/srep34960] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Accepted: 09/15/2016] [Indexed: 11/20/2022] Open
Abstract
Critical soft tissue injuries may lead to a non-functional and insensate limb. In these cases standard reconstructive techniques will not suffice to provide a useful outcome, and solutions outside the biological arena must be considered and offered to these patients. We propose a concept which, after all reconstructive options have been exhausted, involves an elective amputation along with a bionic substitution, implementing an actuated prosthetic hand via a structured tech-neuro-rehabilitation program. Here, three patients are presented in whom this concept has been successfully applied after mutilating hand injuries. Clinical tests conducted before, during and after the procedure, evaluating both functional and psychometric parameters, document the benefits of this approach. Additionally, in one of the patients, we show the possibility of implementing a highly functional and natural control of an advanced prosthesis providing both proportional and simultaneous movements of the wrist and hand for completing tasks of daily living with substantially less compensatory movements compared to the traditional systems. It is concluded that the proposed procedure is a viable solution for re-gaining highly functional hand use following critical soft tissue injuries when existing surgical measures fail. Our results are clinically applicable and can be extended to institutions with similar resources.
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Affiliation(s)
- Oskar C Aszmann
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria.,Christian Doppler Laboratory for Restoration of Extremity Function, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Ivan Vujaklija
- Institute of Neurorehabilitation Systems, Bernstein Focus Neurotechnology Göttingen, University Medical Center Göttingen, Georg-August University, Von-Siebold-Str. 6, 37075 Göttingen, Germany
| | - Aidan D Roche
- Christian Doppler Laboratory for Restoration of Extremity Function, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Stefan Salminger
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria.,Christian Doppler Laboratory for Restoration of Extremity Function, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Malvina Herceg
- Department of Physical and Rehabilitation Medicine, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Agnes Sturma
- Christian Doppler Laboratory for Restoration of Extremity Function, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria.,Master Degree Program "Health Assisting Engineering", University of Applied Sciences FH Campus Wien, Favoritenstraße 226, 1100 Vienna, Austria
| | - Laura A Hruby
- Christian Doppler Laboratory for Restoration of Extremity Function, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Anna Pittermann
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Christian Hofer
- Otto Bock Healthcare Products GmbH, Brehmstraße 16, 1110 Vienna, Austria
| | - Sebastian Amsuess
- Otto Bock Healthcare Products GmbH, Brehmstraße 16, 1110 Vienna, Austria
| | - Dario Farina
- Institute of Neurorehabilitation Systems, Bernstein Focus Neurotechnology Göttingen, University Medical Center Göttingen, Georg-August University, Von-Siebold-Str. 6, 37075 Göttingen, Germany
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24
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Fochtmann A, Binder H, Rettl G, Starlinger J, Aszmann O, Sarahrudi K, Hajdu S. Third degree open fractures and traumatic sub-/total amputations of the upper extremity: Outcome and relevance of the Mangled Extremity Severity Score. Orthop Traumatol Surg Res 2016; 102:785-90. [PMID: 27209033 DOI: 10.1016/j.otsr.2016.04.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Revised: 02/03/2016] [Accepted: 04/08/2016] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Third degree open fractures and traumatic sub-/total amputations of the upper extremity represent severe injuries and are associated with a high rate of functional impairment of the affected extremity. More than 20 years ago, the Mangled Extremity Severity Score (MESS) was introduced to predict amputation following severe lower extremity trauma. However, there have been few studies evaluating MESS in connection with the mangled upper limb. MATERIAL AND METHODS A retrospective medical chart review was performed of all patients diagnosed with the aforementioned fractures of the upper extremity treated at the Department of trauma surgery (level I trauma center) and the Clinical division of plastic and reconstructive surgery at the general hospital of Vienna between 1994 and 2014. RESULTS Fifty-four out of 606 patients (9%) suffered from a total of 61 third degree open fractures or traumatic sub-/total amputations of the upper extremity (Gustilo-Anderson, type IIIA, n=30; Gustilo-Anderson, type IIIB, n=15; Gustilo-Anderson, type IIIC, n=9; traumatic sub-/total amputations, n=7). Thirty-seven out of 54 patients (69%) suffered fractures of the forearm, 10/54 (19%) patients of the humerus and 7/54 (13%) patients of the forearm and the humerus. The median MESS and Injury Severity Score (ISS) for all patients was 5 (range: 3-10) and 9 (range: 4-50), respectively. Seventeen out of 54 patients (31%) were diagnosed with a MESS≥7. Twenty-one out of 54 patients (39%) suffered severe vascular injuries and 22/54 (41%) patients suffered injuries of neural structures. Throughout the therapy process, 6/54 (11%) patients died. Definite limb salvage was achieved in 45 (94%) of the 48 survivors, of whom 9/45 (20%) subjects had a MESS≥7. DISCUSSION It became apparent that definite limb salvage could be achieved in the mangled upper extremity regardless of MESS. It should be noted that in the current study, limb functionality was not assessed. However, without a standardized scoring system, there might be significant risk of salving dysfunctional upper limbs. LEVEL OF EVIDENCE IV: retrospective or historical series.
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Affiliation(s)
- A Fochtmann
- Medical university of Vienna, clinical division of plastic and reconstructive surgery, department of surgery, 18-20, Waehringer Guertel, 1090 Vienna, Austria; Medical university of Vienna, department of trauma surgery, general hospital, Vienna, Austria.
| | - H Binder
- Medical university of Vienna, department of trauma surgery, general hospital, Vienna, Austria.
| | - G Rettl
- Medical university of Vienna, department of trauma surgery, general hospital, Vienna, Austria.
| | - J Starlinger
- Medical university of Vienna, department of trauma surgery, general hospital, Vienna, Austria.
| | - O Aszmann
- Medical university of Vienna, clinical division of plastic and reconstructive surgery, department of surgery, 18-20, Waehringer Guertel, 1090 Vienna, Austria.
| | - K Sarahrudi
- Medical university of Vienna, department of trauma surgery, general hospital, Vienna, Austria.
| | - S Hajdu
- Medical university of Vienna, department of trauma surgery, general hospital, Vienna, Austria.
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25
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Abstract
Although the feasibility of reimplantation has increased greatly with the development of new surgical techniques, long-term functional prognosis is unpredictable. Injury to a major nerve is an important factor in long-term outcome, and prolonged ischemia time also has a negative effect. We present a 26-year-old woman whose right arm was sectioned above the elbow in an accident. The limb presented a complete section, with soft tissue loss of the humeral artery and vein, basilic vein, and cephalic vein. Median and radial nerve tissue was missing, and a supracondylar fracture with substantial loss of the humerus was also observed. During reimplantation surgery, a temporary arterial shunt reduced ischemia time. A venous and arterial bypass was performed, and the 12-month results were good.
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Affiliation(s)
- Meritxell Davins
- Department of Vascular Surgery, Sana Creu i Sant Pau Hospital, Barcelona, Spain.
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Jain S, Rajan S, Srivastava A. Severely comminuted radius fracture presenting as a signature patterned injury. Indian J Orthop 2016; 50:213-7. [PMID: 27053813 PMCID: PMC4800966 DOI: 10.4103/0019-5413.177585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Dilemma still prevails, regarding the exact management of mangled extremity injuries between limb salvage versus amputation, each having there own set of complications. We here present a case of severely comminuted fractures of radius (bag of bones) along with the multiple criss-cross shaped lacerated wounds on the forearm and wrist presenting as a "signature pattern injury" caused by entrapment of the limb in the concrete mixer. MESS score of patient was 8, a score valid for amputation, but contrary, we successfully salvaged the patient's limb with use of radio-carpal distracter. Management of mangled injuries should be individualized, with due consideration to the mechanism and force of injury, associated injuries, and the patient profile.
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Affiliation(s)
- Saurabh Jain
- Department of Orthopaedics, Mahavir Hospital, Indore (M.P.), India,Address for correspondence: Dr. Saurabh Jain, A-2, Mahavir Hospital, Footi Khothi Square, Indore, Madhya Pradesh - 452 009, India. E-mail:
| | - Sunil Rajan
- Department of Orthopaedics, Synergy Hospital, Indore (M.P.), India
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Zeng Q, Cai G, Liu D, Wang K, Zhang X. Successful salvage of the upper limb after crush injury requiring nine operations: a case report. Int Surg 2015; 100:540-6. [PMID: 25785341 DOI: 10.9738/INTSURG-D-14-00018.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Emergency treatment of amputation is one of the most frequently used therapeutic methods for patients with severe upper limb crush injury with a mangled extremity severity score (MESS) of more than 7. With the development of advanced surgical repair techniques and reconstructive technology, cases that once required amputation can now be salvaged with appropriate management, and some limb functions may also be reserved. A patient with a severe upper limb crush injury with a MESS score of 10 was treated in our hospital. The limb was salvaged after 9 surgeries over 10 months. The follow-up visits over the next 18 months post-injury showed that the shoulder joint functions were rated as "excellent" (90) according to the Neer score, the Harris hip evaluation (HHS) for elbow joint functions was "good" (80), and the patient was very satisfied with the overall therapeutic outcome. We conclude from the successful outcome of this extreme injury that salvage attempts should be the first management choice for upper limbs with complex injuries to save as much function as possible. Amputation should only be adopted when the injury is life-threatening or no more function can be saved. The level of evidence was V.
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Abstract
Patients with complex upper extremity injuries represent a unique subset of the trauma population. In addition to extensive soft tissue defects affecting the skin, bone, muscles and tendons, or the neurovasculature in various combinations, there is usually concomitant involvement of other body areas and organ systems with the potential for systemic compromise due to the underlying mechanism of injury and resultant sequelae. In turn, this has a direct impact on the definitive reconstructive plan. Accurate assessment and expedient treatment is thus necessary to achieve optimal surgical outcomes with the primary goal of limb salvage and functional restoration. Nonetheless, the characteristics of these injuries places such patients at an increased risk of complications ranging from limb ischemia, recalcitrant infections, failure of bony union, intractable pain, and most devastatingly, limb amputation. In this article, the authors present an algorithmic approach toward complex injuries of the upper extremity with due consideration for the various reconstructive modalities and timing of definitive wound closure for the best possible clinical outcomes.
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Affiliation(s)
- Zhi Yang Ng
- Department of Orthopaedic Surgery, Alexandra Hospital, Singapore
| | - Morad Askari
- Division of Plastic Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Harvey Chim
- Division of Plastic Surgery, University of Miami Miller School of Medicine, Miami, Florida
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Abstract
Mangled upper extremity injuries usually involve high-impact trauma with crushing and tearing of the limb and its associated soft tissue structures. Such trauma is particularly mutilating because of the nature of the injury and the involvement of structures vital for proper function. Although advancements in flap technique and improvements in bone fixation methods have enabled good functional and clinical outcomes in limb salvage reconstruction, this remains a challenging area. Attempts at limb preservation should be fully exhausted before consideration is given for amputation, which results in significantly decreased function. Here the authors focus on the various modalities of soft tissue coverage available including allogenic substitutes, the adjunctive use of negative pressure wound therapy, and the design and utilization of flaps to address various defect configurations for the goals of wound healing, aesthetics, and functional restoration in the mangled upper extremity.
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Affiliation(s)
- Zhi Yang Ng
- Department of Orthopaedic Surgery, Alexandra Hospital, Singapore
| | | | - Steven L Moran
- Division of Plastic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Harvey Chim
- Division of Plastic Surgery, University of Miami Miller School of Medicine, Florida
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Abstract
BACKGROUND Decision of limb salvage or amputation is generally aided with several trauma scoring systems such as the mangled extremity severity score (MESS). However, the reliability of the injury scores in the settling of open fractures due to explosives and missiles is challenging. Mortality and morbidity of the extremity trauma due to firearms are generally associated with time delay in revascularization, injury mechanism, anatomy of the injured site, associated injuries, age and the environmental circumstance. The purpose of the retrospective study was to evaluate the extent of extremity injuries due to ballistic missiles and to detect the reliability of mangled extremity severity score (MESS) in both upper and lower extremities. MATERIALS AND METHODS Between 2004 and 2014, 139 Gustillo Anderson Type III open fractures of both the upper and lower extremities were enrolled in the study. Data for patient age, fire arm type, transporting time from the field to the hospital (and the method), injury severity scores, MESS scores, fracture types, amputation levels, bone fixation methods and postoperative infections and complications retrieved from the two level-2 trauma center's data base. Sensitivity, specificity, positive and negative predictive values of the MESS were calculated to detect the ability in deciding amputation in the mangled limb. RESULTS Amputation was performed in 39 extremities and limb salvage attempted in 100 extremities. The mean followup time was 14.6 months (range 6-32 months). In the amputated group, the mean MESS scores for upper and lower extremity were 8.8 (range 6-11) and 9.24 (range 6-11), respectively. In the limb salvage group, the mean MESS scores for upper and lower extremities were 5.29 (range 4-7) and 5.19 (range 3-8), respectively. Sensitivity of MESS in upper and lower extremities were calculated as 80% and 79.4% and positive predictive values detected as 55.55% and 83.3%, respectively. Specificity of MESS score for upper and lower extremities was 84% and 86.6%; negative predictive values were calculated as 95.45% and 90.2%, respectively. CONCLUSION MESS is not predictive in combat related extremity injuries especially if between a score of 6-8. Limb ischemia and presence or absence of shock can be used in initial decision-making for amputation.
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Affiliation(s)
- Tolga Ege
- Department of Orthopedics and Traumatology, Gulhane Military Medical Academy, Ankara, Turkey,Address for correspondence: Dr. Tolga Ege, Department of Orthopedics and Traumatology, Gulhane Military Medical Academy, Ankara, Turkey. E-mail:
| | - Aytekin Unlu
- Department of General Surgery, Gulhane Military Medical Academy, Ankara, Turkey
| | - Huseyin Tas
- Department of General Surgery, Gulhane Military Medical Academy, Ankara, Turkey
| | - Dogan Bek
- Department of Orthopedics and Traumatology, Gulhane Military Medical Academy, Ankara, Turkey
| | - Selim Turkan
- Department of Orthopedics and Traumatology, Gulhane Military Medical Academy, Ankara, Turkey
| | - Aytac Cetinkaya
- Department of Infectious Diseases, Gulhane Military Medical Academy, Ankara, Turkey
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Abstract
In this meta-analysis, we aim to evaluate gender differences of lower extremity amputation risk in patients with diabetic foot. Systematic computerized searches of PubMed and Web of Knowledge were performed. The pooled odds ratio (OR) and 95% confidence interval (CI) for amputation risk were calculated. Twenty studies with 15 385 case (present amputation) and 438 760 control (absent amputation) patients were included in the meta-analysis. The pooled crude OR was 1.676 (95% CI 1.307-2.149; Z = 4.07, P = .000). In the retrospective study subgroup, the pooled OR was 1.708 (95% CI = 1.235-2.363; Z = 3.24, P = .001); in the prospective study subgroup, the pooled OR was 1.478 (95% CI = 1.189-1.838; Z = 3.51, P = .000). The pooled adjusted OR was 1.439 (95% CI = 1.238-1.671; Z = 4.76, P = .000). In retrospective study subgroup, the pooled OR was 1.440 (95% CI = 1.208-1.717; Z = 4.07, P = .000); in prospective study subgroup, the pooled OR was 1.478 (95% CI = 1.080-2.024; Z = 2.44, P = .015). No significant publication bias was found. Sensitivity analyses by omitting a heterogeneity study showed the results were robust. In conclusion, our meta-analysis indicates that men with diabetic foot have about one half increased amputation risk than women with diabetic foot. Men with diabetes should receive more complete follow-up and more adequate health education.
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Affiliation(s)
- Zhu-Qi Tang
- Department of Endocrinology, Affiliated Hospital of Nantong University, Nantong City, People's Republic of China
| | - Hong-Lin Chen
- School of nursing, Nantong University, Nantong City, People's Republic of China
| | - Fang-Fang Zhao
- School of nursing, Nantong University, Nantong City, People's Republic of China
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Abstract
OBJECTIVES Much attention has been given to lower extremity amputations that occur more than 90 days after injury, but little focus has been given to analogous upper extremity amputations. The purpose of this study was to determine the reason(s) for desired amputation and the common complications after amputation for those combat-wounded service members who underwent late upper extremity amputation. DESIGN Retrospective case series. SETTING Tertiary trauma center. PATIENTS/PARTICIPANTS All US service members who sustained major extremity amputations from September 2001 to July 2011 were analyzed. INTERVENTION Late (>90 days after injury) upper extremity amputations. MAIN OUTCOME MEASUREMENTS Amputation level(s), time to amputation, age, number of operations, pre/postoperative complications, reason(s) for desiring amputation, and disability outcomes were analyzed. RESULTS Seven of 218 (3.2%) upper extremity amputees had a late upper extremity amputation (>90 days from injury to amputation). The mean and median number of days from injury to amputation was 689 and 678, respectively. The most common preamputation complications were loss of wrist or finger motion (7, 100%), neurogenic pain (4, 57%), and heterotopic ossification (4, 57%). Three (43%) patients (2 persistent and 1 new onset) had neurogenic pain and 2 (29%) had heterotopic ossification after amputation. Only 57% (4 of 7) of amputees used their prostheses regularly. CONCLUSIONS Service members undergoing late upper extremity amputation seem to have different pre- and postoperative complications than those patients undergoing late lower extremity amputations. It was common for the amputee to not wear their prostheses and to experience similar complications after amputation, albeit in a less severe form.
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Abstract
Management of major limb injuries is a daunting challenge, especially as many of these patients have severe associated injuries. In trying to save life, often the limb is sacrificed. The existing guidelines on managing such trauma are often confusing. There is scope to lay down such protocols along with the need for urgent transfer of such patients to a multispecialty center equipped to salvage life and limb for maximizing outcome. This review article comprehensively deals with the issue of managing such major injuries.
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Abstract
OBJECTIVE Assess effectiveness of Injury Severity Score (ISS) in predicting injury severity in combat-related amputations. DESIGN Retrospective evaluation of prospectively collected data. SETTING Military medical center. PATIENTS One hundred and nine patients with major extremity amputations sustained in overseas combat. INTERVENTION Standard combat casualty care. MAIN OUTCOME MEASUREMENTS Difference in injury severity as measured by ISS, numbers of extremity(s) amputated, number of associated injuries, blood products used, intensive care unit length of stay, hospital length of stay in those with an upper extremity amputation (UEA) compared with those with an isolated lower extremity amputation. RESULTS Thirteen patients (11.9%) sustained at least one UEA. Patients with an UEA had a greater number of amputations per casualty compared with patients with a lower extremity alone (2.5 vs. 1.5; P < 0.001). The mean hospital length of stay (P = 0.02) and intensive care unit length of stay (P = 0.02) were significantly greater in those with an UEA. Mean blood product utilization was also significantly greater in those with an upper extremity amputation (P < 0.05). There was no difference in ISS between the two groups (P > 0.05). CONCLUSIONS The presence of an UEA is associated with increased injury severity as evident by increased intensive care unit requirements, blood product utilization, and hospital length of stay. ISS underestimates the severity of injury and therefore resource utilization in patients with multiple combat-related amputations. Recognition of this limitation in addition to the development of a military-specific ISS is required for more effective resource utilization to continue to improve combat casualty care. LEVEL OF EVIDENCE Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Bakker A, Moseley J, Friedrich J. Vehicle factors and outcomes associated with hand-out-window motor vehicle collisions. J Trauma Acute Care Surg 2013; 74:687-91. [DOI: 10.1097/ta.0b013e31827e1857] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Merchant N, Scalea T, Stein D. Can CT Angiography Replace Conventional Bi-Planar Angiography in the Management of Severe Scapulothoracic Dissociation Injuries? Am Surg 2012. [DOI: 10.1177/000313481207800823] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Severe scapulothoracic dissociation (SSTD) (Type III or IV; Zelle classification) is often life-threatening and is commonly associated with other devastating injuries. Rapid evaluation, including of the vascular system, is critical to limit the time to definitive therapy. CT angiography (CTA) has evolved as a diagnostic tool, replacing angiography (angio) as it can simultaneously evaluate bony, soft tissue, and vascular injuries. We hypothesized that CTA would be useful in evaluating patients with SSTD. We retrospectively reviewed the trauma registry between June 2002 and June 2010 to identify patients over 18 years of age who sustained SSTD. Patients that were transferred or died before diagnostic imaging were excluded. Comparisons were made between the group that underwent angio before surgery compared with CTA with regards to outcome and length of hospital and intensive care unit stay. Fourteen patients were identified with Type III or IV SSTD over the study period. In the CTA group, mean Injury Severity Score was higher, but time to definitive operative intervention was significantly shorter. There was no difference in amputation rates or mortality. Replacing arteriography with CTA in the preoperative workup of patients with SSTD reduces time to surgery. Despite a greater injury severity in the group in which CTA was used as the primary imaging modality, length of stay, amputation rates, and mortality were no different. CTA can be safely used to evaluate patients with suspected SSTD.
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Affiliation(s)
| | - Thomas Scalea
- R. Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, Maryland
| | - Deborah Stein
- R. Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, Maryland
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Abstract
The management of a mangled extremity continues to be a matter of debate. With modern advances in trauma resuscitation, microvascular tissue transfer, and fracture fixation, severe traumatic extremity injuries that would historically have been amputated are often salvaged. Even if preserving a mangled limb is a technical possibility, the question is often raised whether the end result will also be functional and what treatment would lead to the best patient outcome. The road to salvage is often prolonged with significant morbidity, reoperations, financial costs, and even mortality in some instances. Numerous factors have been implicated in the outcome of these injuries, and a number of scoring systems have been designed in an attempt to help guide the treating surgeon in the acute phase. However, much controversy remains on the ability of these grading systems to predict successful salvage of the mangled extremity. In this review, we discuss the mechanisms of injury, various available scoring systems, initial management, outcome and specific differences between lower and upper extremity trauma injuries.
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Affiliation(s)
- Mark L. Prasarn
- Department of Orthopaedic Surgery, University of Texas Medical School at Houston, Houston, TX USA
| | | | - Peter Kloen
- Department of Orthopaedic Surgery, Academic Medical Center, G4-N, Meibergdreef 9, 1100 DD Amsterdam, The Netherlands
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Weber DJ, Shoham DA, Luke A, Reed RL 2nd, Luchette FA. Racial odds for amputation ratio in traumatic lower extremity fractures. ACTA ACUST UNITED AC 2011; 71:1732-6. [PMID: 22182881 DOI: 10.1097/TA.0b013e31823c5f94] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Recent studies have demonstrated that black patients receive substandard care compared with white patients across healthcare settings. The purpose of this study was to evaluate the association of race on the management (salvage vs. amputation) of traumatic lower extremity open fractures. METHODS Data analysis was conducted using the American College of Surgeon's National Trauma Data Bank. Open tibial and fibular (OTFF) and open femoral (OFF) fractures among adults above the age of 18 were identified by International Classification of Diseases, 9th Revision codes. Injuries were identified as amputated based on the presence of one of three types of knee amputations. Statistical analysis included logistic regression stratified for sex, age, race, mechanism of injury, severity, and insurance type. RESULTS From the National Trauma Data Bank, 10,082 OFF and 22,479 OTFF were identified. Amputation rates were 3.1% for OFF and 4.2% for OTFF. With age stratification, the ratio of amputation odds for blacks to amputation odds for whites (i.e., the Racial Odds for Amputation Ratio [ROAR]) demonstrated a significant interaction between black and age in both the OFF (p = 0.028) and OTFF (p = 0.008) groups. In younger patients, a lower ROAR (p = 0.016) favored salvage in blacks, while the ROAR in older patients favored amputation in blacks (p = 0.013). The higher prevalence of penetrating injuries in blacks only accounted for 12.7% of the lower ROAR among younger adults. CONCLUSIONS There exists a racial disparity in the management of lower extremity open fractures. Older blacks have greater odds of amputation that is not explained by mechanism. In contrast, younger blacks have lower odds for amputation that is only partially explained by mechanism of injury.
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Scalea TM, DuBose J, Moore EE, West M, Moore FA, McIntyre R, Cocanour C, Davis J, Ochsner MG, Feliciano D. Western Trauma Association critical decisions in trauma: management of the mangled extremity. J Trauma Acute Care Surg 2012; 72:86-93. [PMID: 22310120 DOI: 10.1097/TA.0b013e318241ed70] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The operative management of mangled extremities after trauma remains controversial. We have sought to develop an evidence-based algorithm to help guide practitioners when faced with these relatively infrequent but very challenging clinical dilemmas. METHODS The Western Trauma Association Critical Decisions Committee queried the literature to identify high-quality managements that would help guide the care of mangled extremities. When good data were not available, the Committee relied on expert opinions, either from the literature or from our senior members. RESULTS Virtually, all the scoring systems used to guide therapy have not been proven to be valid. Hemodynamically unstable patients who failed to respond to initial resuscitation should be taken to the operating room for exploration and vascular control. Those who are stable should undergo a stepwise vascular and neurologic evaluation process. A comprehensive evaluation of factors that may help predict the appropriateness of limb salvage should be done in the operating room. Patients who are not candidates for salvage should undergo primary amputation. Those who are should undergo attempts at limb salvage. CONCLUSIONS Patients with mangled extremities remain a significant management challenge. This algorithm represents a guideline based on the best evidence available in the literature and expert opinion. It does not establish a standard of care. It should provide a framework for treating physicians and other healthcare professionals to guide therapy, considering individual patients' clinical status and institutional resources.
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Nikkhah D, Bhat W, Williams A, Bourke G. Upper limb salvage following near skeletalisation. J Plast Reconstr Aesthet Surg 2011; 65:836-7. [PMID: 22137976 DOI: 10.1016/j.bjps.2011.11.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2011] [Revised: 10/12/2011] [Accepted: 11/10/2011] [Indexed: 11/15/2022]
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Abstract
Acquired upper extremity amputations beyond the finger can have substantial physical, psychological, social, and economic consequences for the patient. The hand surgeon is one of a team of specialists in the care of these patients, but the surgeon plays a critical role in the surgical management of these wounds. The execution of a successful amputation at each level of the limb allows maximum use of the residual extremity, with or without a prosthesis, and minimizes the known complications of these injuries. This article reviews current surgical options in performing and managing upper extremity amputations proximal to the finger.
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Affiliation(s)
- Jeffrey A Marchessault
- Walter Reed National Military Medical Center, Integrated Department of Orthopedics and Rehabilitation, 8901 Wisconsin Avenue, Bethesda, MD20889, USA.
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Abstract
Complex wounds present a challenge to both the surgeon and patient in operative management, long-term care, cosmetic outcome, and effects on lifestyle, self-image, and general health. Each patient with complex wounds usually manifests multiple risk factors for their development. This article focuses on complex wounds involved with traumatic and orthopedic blunt or penetrating injuries, particularly in the extremities, as well as massive soft tissue infections including necrotizing fasciitis, gas gangrene, and Fournier gangrene. The principles of management of complex wounds involve assessing the patient's clinical status and the wound itself, appropriate timing of intervention, providing antibiotic therapy when necessary, and planning and executing surgical therapy, including the establishment of a clean wound bed and closure/reconstructive strategies.
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Affiliation(s)
- Habeeba Park
- Department of Surgery, Sinai Hospital of Baltimore, 2401 West Belvedere Avenue, Baltimore, MD 21215, USA
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Tos P, Artiaco S, Titolo P, Conforti LG, Battiston B. Limits of reconstruction in mangled hands. Chir Main 2010; 29:280-2. [PMID: 20724198 DOI: 10.1016/j.main.2010.07.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/02/2010] [Accepted: 07/02/2010] [Indexed: 10/19/2022]
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Abstract
OBJECTIVES The purpose of this study was to propose a new classification system for open fractures developed by the Classification Committee of the Orthopaedic Trauma Association. SETTING Academic and Level I trauma center. PATIENTS/PARTICIPANTS Consecutive patients with open fractures. MAIN OUTCOME MEASUREMENTS Open fracture classification scale. RESULTS Evaluation of 34 factors identified through systematic literature review and ranking in order of importance by our panel resulted in consensus on five essential categories of open fracture severity assessment: skin injury, muscle injury, arterial injury, contamination, and bone loss. These categories were chosen with particular attention paid to avoiding redundancy with existing tools for assessment of fracture configuration. Evaluation of the system through prospective data collection revealed that the five categories were widely applicable to open fractures, but the subcategories of open fracture characteristics required alteration to reflect clinically important parameters for open fracture severity stratification. Skin injury was best assessed by its potential for approximation rather than laceration length. Muscle injury required quantitative and qualitative assessment of potential for function. The effects of arterial injury were most accurately assessed through distal limb ischemia. The depth and nature of contamination were important indicators of overall contamination significance. Bone loss was best assessed quantitatively. CONCLUSIONS The proposed Orthopaedic Trauma Association Classification of Open Fractures is a scientifically derived assessment tool for determining the severity of open fractures. This tool will require further testing to establish validity characteristics and determine its clinical use compared with existing open fracture classification systems.
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Prichayudh S, Verananvattna A, Sriussadaporn S, Sriussadaporn S, Kritayakirana K, Pak-art R, Capin A, Pereira B, Tsunoyama T, Pena D. Management of upper extremity vascular injury: outcome related to the Mangled Extremity Severity Score. World J Surg 2009; 33:857-63. [PMID: 19189175 DOI: 10.1007/s00268-008-9902-4] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND The Mangled Extremity Severity Score (MESS) is an objective criterion for amputation prediction after lower extremity injury as well as for amputation prediction after upper extremity injury. A MESS of >or=7 has been utilized as a cutoff point for amputation prediction. In this study, we examined the result of upper extremity vascular injurty (UEVI) management in terms of the amputation rate as related to the MESS. METHODS During January 2002 to July 2007, we reviewed patients with UEVIs at our institution. Data collections included demographic data, mechanism of injuries, injury severity score (ISS), ischemic time, MESS, pathology of UEVI, operative management, and amputation rate. Decisions to amputate the injured limbs at our institution were made individually by clinically assessing limb viability (i.e., color and capillary refill of skin; color, consistency, and contractility of muscles) regardless of the MESS. The outcome was analyzed in terms of the amputation rate related to the MESS. RESULTS There were 52 patients with UEVIs in this study: 25 (48%) suffered blunt injuries and 27 (52%) suffered penetrating injuries. The age ranged from 15 to 59 years (mean 28.7 years). The mean ischemia time was 10.07 h. The mean ISS was 17.52. There were 12 patients (23%) with subclavian artery injuries, 3 patients (5.76%) with axillary artery injuries, 18 patients (34.61%) with brachial artery injuries, and 19 patients (36.54%) with radial artery and/or ulnar artery injuries. Primary repairs were performed in 45 patients (86.54%), with ligations in 3 patients (5.77%). An endovascular stent-graft was used in one patient (1.92%). Primary amputations were performed in three patients (5.77%). Secondary amputations (amputation after primary operation) were done in 4 of 49 patients (secondary amputation rate 8.16%). All amputation patients suffered blunt injuries and had a MESS of >or=7 (range 7-11). The overall amputation rate in this study was 13.46% (7/52 patients). Multivariate analysis revealed that the only factor significantly associated with amputation was the MESS. There were no amputations in 33 patients who had a MESS of <7. We could avoid amputation in 12 of 19 patients who had a MESS>or=7. There were no mortalities among 52 UEVI patients. CONCLUSIONS MESS, an outcome score used to grade the severity of extremity injuries, correlates well with the risk of amputation. Nevertheless, a MESS of >or=7 does not always mandate amputation. On the other hand, the MESS is a better predictor for patients who do not require amputation when the score is <7. The decisions to amputate in patients should be made individually based on clinical signs and an intraoperative finding of irreversible limb ischemia.
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Affiliation(s)
- Supparerk Prichayudh
- Department of Surgery, Faculty of Medicine, Chulalongkorn University, 1873 Rama 4 Road, Pathumwan, Bangkok, 10330, Thailand.
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Simmons JD, Schmieg RE, Porter JM, D'souza SE, Duchesne JC, Mitchell ME. Brachial Artery Injuries in a Rural Catchment Trauma Center: Are the Upper and Lower Extremity the Same? ACTA ACUST UNITED AC 2008; 65:327-30. [DOI: 10.1097/ta.0b013e31817fbde4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
The management of patients with severe extremity injuries involves focused efforts at limb salvage and mitigation of potential infectious complications. An in-depth understanding of the proper approach to initial management is essential, as it may impact eventual outcome. The use of established scoring systems may predict those at greater risk and enable expeditious utilization of appropriate consultation services. This case-based review highlights critical aspects of patient care and provides a framework for the role of the Emergency Physician.
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Affiliation(s)
- Regina Oakes
- Department of Emergency Medicine, Detroit Receiving Hospital-Emergency Medicine Residency, Wayne State University School of Medicine, Detroit, Michigan 48201, USA
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Einsiedel T, Dieterich J, Kinzl L, Gebhard F, Schmelz A. Extremitätenerhalt durch tibiokalkaneare Arthrodese nach Pirogoff. Orthopäde 2008; 37:143-52. [DOI: 10.1007/s00132-008-1196-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Abstract
The management of open fractures continues to provide challenges for the orthopedic surgeon. Despite the improvements in technology and surgical techniques, rates of infection and nonunion are still troublesome. Principles important in the treatment of open fractures are reviewed in this article. Early antibiotic administration is of paramount importance in these cases, and when coupled with early and meticulous irrigation and debridement, the rates of infection can be dramatically decreased. Initial surgical intervention should be conducted as soon as possible, but the classic 6 h rule does not seem to be supported in the literature. All open fractures should be addressed for the risk of contamination from Clostridium tetani. When possible, early closure of open fracture wounds, either by primary means or by flaps, can also decrease the rate of infection, especially from nosocomial organisms. Early skeletal stabilization is necessary, which can be accomplished easily with temporary external fixation. Adhering to these principles can help surgeons provide optimal care to their patients and assist them in an early return to function.
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Affiliation(s)
- William W Cross
- Department of Orthopaedic Surgery, University of Minnesota Medical School, 2450 Riverside Ave., Ste R 200, Minneapolis, MN 55454, USA
| | - Marc F Swiontkowski
- Department of Orthopaedic Surgery, University of Minnesota Medical School, 2450 Riverside Ave., Ste R 200, Minneapolis, MN 55454, USA,Address for correspondence: Dr. Marc F. Swiontkowski, Department of Orthopaedic Surgery, University of Minnesota Medical School, 2450 Riverside Ave., Suite R200, Minneapolis, MN 55454, USA. E-mail:
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